SCLEROTHERAPY INFORMED CONSENT FORM This form is ...

SCLEROTHERAPY INFORMED CONSENT FORM
This form is designed to provide you with the information you need to make an
informed decision about whether to have sclerotherapy performed. If you have any
questions or do not understand any potential risks, please do not hesitate to ask me.
What is Sclerotherapy?
Sclerotherapy is a popular method of eliminating varicose veins and superficial
telangiectasias (“spider veins”) in which a solution, called a sclerosing agent, is injected
into the veins.
Does Sclerotherapy work for everyone?
The majority of persons who have sclerotherapy performed will be clear of their enlarged
veins or at least see good improvement. Unfortunately, however, there is no guarantee
that sclerotherapy will be effective in every case. Approximately 10% of patients who
undergo sclerotherapy have poor to fair results. (“Poor results” means that the veins have
not totally disappeared after six treatments.) In very rare instances, the patient’s
condition may become worse after sclerotherapy treatment.
How many treatments will I need?
The number of treatments needed to clear or improve the condition differs from patient to
patient, depending on the extent of varicose and spider veins present. One to six or more
treatments may be needed; the average is four. Individual veins usually require one to
three treatments.
What are the most common side effects?
The most common side effects experienced with sclerotherapy treatment are:
1. Transient hyperpigmentation-Approximately 30% of patients who undergo
sclerotherapy notices a discoloration of brown streaks after treatment. In almost
every patient, the veins become darker immediately after the procedure. In rare
instances, the darkening of the vein may persist for a year or more.
Hyperpigmentation is more common in olive or darker skinned patients.
2. Sloughing-Sloughing occurs in less than 5% of patients who receive sclerotherapy.
Sloughing consists of a small ulceration at the injection site that heals slowly. It may
resemble a sore or cigarette burn. A blister may form, open, and become ulcerated.
The scar that forms will be permanent.
3. Neovascularization-The development, usually temporary, of new tiny blood vessels
around the injection site.

4. Allergic Reactions-Very rarely, a patient may have an allergic reaction to the
sclerosing agent used. The risk of an allergic reaction is greater in patients who have
a history of allergies. The worst allergic reaction could result in inability to breathe
and death.
5. Pain-A few patients may experience moderate to severe pain and some bruising,
usually at the injection sites. The veins may be tender to the touch after treatment,
and an uncomfortable sensation may run along the vein route. The pain is usually
temporary, in most cases lasting 1 to 7 days.
6. Itching-Depending on the type of solution used, you may experience mild itching
along the vein route. This itching normally lasts 1 to 2 days.
What are the other side effects?
Other side effects include a burning sensation during injection of some solutions,
neovascularization (the development-usually temporary-of new tiny blood vessels),
transient phlebitic-type reactions (swelling of the vein might cause the ankles to swell),
temporary superficial swellings or wheals (similar to hives), and, very rarely, wound
infection, poor healing, or scarring.
Phlebitis is a very rare complication, seen in approximately 1 of every 1000 patients
treated for varicose veins 3 to 4 mm or greater in diameter. The dangers of phlebitis
include the possibility of pulmonary embolus (a blood clot to the lungs-which could be
fatal) and postphlebitis syndrome, in which the blood clot is not carried out of the legs,
resultant swelling of the legs.
What are the possible complications if I do not have sclerotherapy?
In cases of large varicose veins (greater than 3 to 4 mm in diameter), spontaneous
phlebitis and/or thrombosis may occur with the associated risk of possible pulmonary
emboli. Additionally, large skin ulcerations may develop in the ankle region of patients
with long-standing varicose veins with underlying venous insufficiency. Rarely these
ulcers may hemorrhage or become cancerous.
Are there other procedures to treat varicose veins and telangiectasias? What are their
side effects?
Vein stripping and/or ligation may also be used to treat large varicose veins. This
generally requires a hospital stay and may be performed under general anesthesia. Risks
of vein stripping or ligation include permanent nerve damage and possible pulmonary
emboli, infection, and permanent scarring. General anesthesia has some associated
serious risks, including paralysis, brain damage and death.
What if I experience a problem after receiving sclerotherapy?
If you notice any adverse reaction, please call the office immediately.
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By signing below, I acknowledge that I have read the foregoing informed consent form and that the doctor
has adequately informed me of the risks of sclerotherapy treatment, alternative methods of treatment, and
the risks of not treating my condition. I hereby request and consent to sclerotherapy treatment performed
by Dr. Rotter.
Patient’s Signature_________________________________________Date__________________